Pelvic floor dysfunction: symptoms, causes, exercises and treatment

Pelvic floor dysfunction is a label for a group of problems, and symptoms depend on which part of the pelvic floor is affected. They fall into bladder, bowel and prolapse-related groups, and they can occur together.

For the bladder, the NHS describes urinary incontinence: leaking when you cough, sneeze or exercise (stress incontinence), or leaking with a sudden urge to pee (urge incontinence). NICE CKS defines stress urinary incontinence as involuntary leakage on effort, exertion, sneezing or coughing, and urgency urinary incontinence as leakage accompanied or preceded by urgency.

For the bowel, the NHS lists poo leaking out without being able to stop it, feeling you need to poo but not getting to the toilet in time, not being able to get fully clean after going to the toilet, and streaks or stains in underwear.

For prolapse, the NHS lists a feeling of heaviness, discomfort or pressure in your lower tummy or vagina, feeling or seeing a bulge or lump inside or coming out of the vagina, pain, discomfort or numbness during sex, problems pooing such as constipation, and problems peeing such as feeling the bladder is not emptying fully or leaking a small amount of pee when you cough, sneeze or exercise.

Bladder & Bowel Community explains that the pelvic floor muscles are layers of muscle stretched like a hammock from the pubic bone at the front to the bottom of the backbone. They support the openings through the pelvic floor: the back passage and bladder outlet in men, and the back passage, vagina and bladder outlet in women. If the muscles are weakened or not in good condition, they cannot support those openings effectively.

The NHS says weak or damaged pelvic floor muscles can cause urinary incontinence, and that weak pelvic floor muscles may lead to prolapse. When a muscle is not exercised it weakens through lack of use, the charity says, and pelvic floor muscles are no exception.

Pelvic floor dysfunction is not always weakness. The NHS pelvic pain page lists pelvic floor muscle exercises among the physiotherapy options for pelvic pain, and our separate guide on overactive pelvic floor covers muscles that are too tight.

Treatment depends on the type of problem and its severity. For urinary incontinence, the NHS says conservative treatments that do not involve medicines or surgery are tried first: lifestyle changes, pelvic floor muscle training (Kegel exercises) and bladder training. After that, medicine or surgery may be considered.

Lifestyle measures the NHS lists include reducing caffeine, altering how much fluid you drink (drinking too much or too little can make incontinence worse) and losing weight if overweight. A GP may refer you to a specialist to start a pelvic floor muscle training programme, which should include at least 8 contractions at least 3 times a day and last for at least 3 months. NICE CKS says women with stress incontinence should be offered a trial of at least 3 months of supervised pelvic floor muscle training, and women with urgency incontinence at least 6 weeks of bladder training.

The NHS also describes electrical stimulation if you cannot contract your pelvic floor muscles, biofeedback (which it says has little good evidence of significant benefit but may help motivation), vaginal cones, and bladder training for urge incontinence, which usually lasts at least 6 weeks. Duloxetine may be an option for stress incontinence if surgery is unsuitable, and antimuscarinic medicines for urge incontinence if bladder training does not work.

For prolapse, the NHS says treatment depends on which organs have prolapsed and how severely, and may include hormone treatment, vaginal support pessaries, physiotherapy and pelvic floor muscle training with a specialist women’s health physiotherapist, and surgery if the prolapse is severe. If you have no symptoms or the prolapse is not bothering you, you may not need treatment.

For bowel incontinence, a GP might recommend a review of diet and medicines, medicines to make you poo less often such as loperamide or to soften poo, and products such as pads. A specialist service can recommend pelvic floor and sphincter exercises (biofeedback) and techniques to empty your bowels fully (bowel retraining), and surgery is possible if other treatments have not helped.

The NHS says you can feel your pelvic floor muscles if you imagine stopping yourself peeing and passing wind. To do the exercises, squeeze the pelvic floor muscles quickly without pulling your tummy in, hold the squeeze for 2 seconds, relax the muscles, and repeat 10 times, breathing normally. Aim to gradually increase the hold to 10 seconds. You may have to do the exercises for a few months before you see any benefit.

Bladder & Bowel Community describes slow pull-ups (holding as long as you can, up to 10 seconds, resting 3 or 4 seconds, building from 5 to 8 to 12 repeats) and fast pull-ups (building from 5 up to 10), repeated 3 times a day, and adds that you should breathe naturally and avoid tightening your buttocks, legs and upper tummy. It advises talking to a continence adviser or physiotherapist to make sure you are doing them correctly.

If you cannot feel the muscles working, ask your GP or a specialist women’s or men’s health physiotherapist to assess you rather than carrying on regardless, since the NHS says the specialist will assess whether you can contract the pelvic floor muscles and by how much.

Bladder & Bowel Community says a long history of constipation can weaken the pelvic floor muscles in both men and women, and that they can also be weakened by surgery in the pelvic area. In women, it says the most common cause of damage is the strain and stretching of childbirth, with large babies and the use of forceps able to increase this damage, and muscle tearing or episiotomies causing further damage.

The NHS lists risk factors for incontinence and prolapse that it says you can influence: being overweight, smoking (because coughing puts pressure on the pelvic floor), constipation and straining, lifting, and high-impact exercise such as jogging, which it suggests replacing with strengthening exercise such as pilates. NICE CKS says the main risk factor for any type of urinary incontinence is older age.

A GP will ask about your symptoms and examine you. NICE CKS says assessment of urinary incontinence in women involves taking a detailed history, a physical examination including a pelvic exam, and urine dipstick and kidney function tests where appropriate.

For prolapse, the NHS says the GP may use a speculum to see whether there is a prolapse, and it may be graded from 1 to 4. For bowel incontinence, the GP might examine your tummy and inside your bottom with a gloved finger, ask for a poo sample, and refer you for blood tests, a colonoscopy or an ultrasound scan. You can ask for a chaperone or a female doctor.

NHS continence services, staffed by specialist nurses and specialist physiotherapists, should be able to diagnose your condition and start treating you. A GP can refer you to your local service and in some cases you can refer yourself.

For bowel incontinence, the NHS says to ask for an urgent GP appointment or get help from NHS 111 if your poo is black or dark red or you have bloody diarrhoea. See a GP if you have changes in your poo that are not getting better.

The NHS says to see a GP if you have a lump in or around your vagina or any other symptoms of prolapse. For new or unexplained pelvic pain, the NHS lists severe or worsening pain, fainting, or heavy vaginal bleeding as reasons to call 999 or go to A&E.

Bladder & Bowel Community says the most common cause of damage to the pelvic floor in women is the strain and stretching involved in childbirth. The NHS says pregnancy-related pelvic girdle pain is a different problem, from stiffness or uneven movement of the pelvic joints, though physiotherapy for it may also include exercises to strengthen the pelvic floor.

The NHS lists physiotherapy and pelvic floor muscle training, usually with a specialist women’s health physiotherapist, as one of the treatment options for prolapse, and a GP can refer you if you have symptoms such as a bulge, leaking or problems emptying your bladder or bowel.

On the NHS, start with your GP or, in some cases, refer yourself to a continence service. The NHS says continence services are staffed by specialist nurses and specialist physiotherapists, and that NHS physiotherapy for prolapse is usually with a specialist women’s health physiotherapist.

Some people choose a private pelvic health physiotherapist. The Pelvic Obstetric and Gynaecological Physiotherapy (POGP) publishes free booklets for patients, including on pelvic floor muscle exercises for women. Whichever route you use, ask the practitioner to check that you are contracting the right muscles.