Pelvic Floor Dysfunction: Why Kegels Aren't Always the Answer

The two types of pelvic floor dysfunction — and why the difference matters

The pelvic floor is a group of muscles that run from the pubic bone to the tailbone, forming a hammock-like structure that supports the bladder, uterus, and bowel. Like any muscle group, it can be too weak or too tight. Most pelvic health advice defaults to the first scenario. The second — a hypertonic, or too-tight, pelvic floor — is dramatically underdiagnosed.

Hypotonic pelvic floor: the muscles are weak or poorly coordinated. Symptoms include stress urinary incontinence (leaking when you cough, sneeze, or exercise), pelvic organ prolapse, and difficulty generating the muscular engagement needed for orgasm. This is the version Kegels help.

Hypertonic pelvic floor: the muscles are in chronic tension — essentially a state of sustained contraction. Symptoms include painful sex (dyspareunia), vaginismus, chronic pelvic or low back pain, difficulty fully emptying the bladder, and tailbone pain. Kegels worsen this. You cannot strengthen a muscle that's already in maximal contraction.

The Kegel advice gap that's making people worse

Every gynecology appointment, every women's magazine, every postpartum care guide: do your Kegels. It's one of medicine's most reflexive recommendations. And it's actively harmful for a significant proportion of women with pelvic floor problems.

A woman with hypertonic pelvic floor dysfunction doing Kegels daily is adding contraction to an already-contracted muscle system. Pain worsens. Symptoms worsen. She's told she's not doing them correctly and to try harder. Most women in this situation spend years cycling through this before reaching a pelvic floor physiotherapist who identifies the actual problem in a single appointment.

What actually works — by presentation type

For hypotonic pelvic floor (incontinence, prolapse), the evidence hierarchy looks like this: pelvic floor PT with biofeedback first, progressing to more intensive physiotherapy if needed, with pessaries and surgical options as escalation for prolapse specifically.

For hypertonic pelvic floor (pain, vaginismus, dyspareunia), the treatment is fundamentally different: myofascial release techniques, trigger point therapy, pelvic floor downtraining rather than strengthening, and in some cases TENS (transcutaneous electrical nerve stimulation) for pain relief. Dilator therapy for vaginismus is supported by evidence when combined with pelvic floor PT rather than used alone.

• →Ask for a referral to a pelvic floor physiotherapist, not just a referral to "do Kegels." A physiotherapist performs an internal assessment that identifies whether your floor is hypo- or hypertonic — the starting point for any treatment plan.
• →Tell your OB-GYN specifically if you experience pain with sex, difficulty fully emptying your bladder, or chronic tailbone or pelvic pain — these are hypertonic flags that should redirect away from Kegel advice.
• →Use the Pelvic Floor Disorders Network directory (pfdn.org) or the APTA Academy of Pelvic Health to find a specialist in your area.
• →If you've been told your pelvic pain is "just how it is" or "part of being a woman," get a second opinion. The research is clear that chronic pelvic pain is treatable in most cases when correctly diagnosed.