Overactive (tight) pelvic floor: symptoms, causes and relaxation

The pelvic floor is a group of muscles that stretches across the base of the pelvis. According to the St George's leaflet, a strong pelvic floor is important for supporting the pelvic organs and for controlling continence and bowel movements. The leaflet adds that these muscles also need to be able to relax, so that you can have sex comfortably and empty the bladder and bowel properly.

Overactivity describes the muscles failing to switch off. Pelvic floor muscles can become tight or go into spasm from overactivity like any other muscle, in the words of the leaflet. The muscles may sit at a higher resting tension than they should, or they may not release when you try to let go, for instance when passing urine or having a bowel movement.

This is why a tight pelvic floor is often described with other terms such as hypertonic, non-relaxing or overactive. They all point to the same idea: the problem is too much muscle tension, rather than too little strength.

Many people have heard the general advice to do pelvic floor exercises. That advice is aimed at weakness, and it can be unhelpful if the real issue is tension. The Royal United Hospitals Bath leaflet points out that if the pelvic floor is tense it is very difficult to contract it effectively, and that you may feel you are not squeezing hard enough simply because the muscle is already tight when you start.

The St George's leaflet lists overloading as one possible cause: too much pelvic floor exercise and not enough relaxation. It also says that when muscles are both tight and weak, tension should be treated first, and strengthening exercises prescribed only once the muscles have reached a normal resting tone.

Because tightness and weakness can feel confusing from the inside, a hands-on assessment by a physiotherapist who works with pelvic health is the usual way to tell them apart. The leaflets from both hospitals recommend speaking to a pelvic physiotherapist for individual help and note that exercise programmes are often tailored to the person.

The symptoms can involve the bladder, the bowel, sex and general pelvic pain. The list below follows the signs and symptoms named in the St George's leaflet. None of them is specific to an overactive pelvic floor on its own, which is part of why the pattern and an examination matter.

• Difficulty urinating and emptying the bladder, or an interrupted urine flow.

• Painful urination.

• Constipation, or pain during or after bowel movements.

• Pain in the lower back, pelvis, hips, coccyx, genitals or rectum.

• Pain during intercourse.

• Pain when you insert a tampon or have a gynaecological examination.

• Pelvic floor spasms.

• Pain when you do pelvic floor strengthening exercises.

The St George's leaflet gives a list of possible causes rather than a single explanation. It includes overloading the pelvic floor with too much exercise and too little relaxation, intense abdominal core exercises or holding in the stomach, pelvic surgery including prolapse surgery and hysterectomy, pelvic infection or inflammation, recurrent infections such as cystitis or thrush, pelvic trauma, poor posture and emotional factors.

The leaflet also says overactivity is commonly linked with painful bladder syndrome, vaginismus, vulvodynia and endometriosis. The Royal United Hospitals Bath leaflet similarly associates an over-active pelvic floor with bladder and bowel pain and dysfunction, pain with intercourse, and chronic stress or anxiety. Anxiety and stress can cause tension in the pelvic floor, according to the St George's leaflet.

For many people more than one factor is involved, and sometimes no clear trigger is found. Knowing the likely contributors is mainly useful for shaping the approach to treatment, rather than for assigning blame.

The leaflets describe relaxation as the main strategy and suggest it is done with professional guidance. The approaches below are those named in the St George's and Royal United Hospitals Bath leaflets. They are general descriptions, not a personal programme.

• Deep diaphragmatic breathing: breathing into the belly rather than the upper chest, with the hands resting on the abdomen so the belly moves forwards on the in-breath.

• Lower abdominal relaxation: allowing the lower tummy to relax and bulge forwards, because relaxing the lower abdominal muscles helps relax the pelvic floor.

• Pelvic floor muscle relaxation: lying on the back with a pillow under the knees, or on the side with a pillow between the thighs, noticing tension around the openings of the pelvis and letting the muscles drop without straining. The leaflet says this should not feel uncomfortable.

• Stretches held for 5 to 10 slow breaths, such as the butterfly, legs up the wall in a V shape and knee hugs, as set out in the Royal United Hospitals Bath leaflet.

• Whole-body relaxation and good posture, because anxiety and stress can cause tension in the pelvic floor and good posture helps the diaphragm, pelvic floor and abdominal muscles work together.

Pelvic floor tension can be a real contributor to symptoms, but it is not a diagnosis you should make for yourself. The NHS pelvic pain page notes that pelvic pain can have many causes, including infections and conditions that affect the bowel, bladder or reproductive organs, and that some causes can be serious and need urgent treatment.

It advises seeing a GP if you have pelvic pain that comes and goes or does not go away, bloating that comes and goes or does not go away, unexplained weight loss, feeling full quickly or having no appetite, or constipation or diarrhoea that does not go away. It advises getting help from NHS 111 if you have pelvic pain and find it difficult to pee or poo, have blood in your pee or poo, unusual vaginal discharge or bleeding, pain when peeing, or a very high temperature. It says to call 999 or go to A&E if the pain is severe, getting worse, or hurts when you move or touch the area, or if you feel faint or pass out.

The NHS adds that treatment depends on the cause, and that a GP might suggest antibiotics, painkillers, physiotherapy such as exercises for the pelvic floor muscles, or hormone treatments, and may refer you for tests or to a specialist.