If there is one piece of pelvic floor advice most women have heard, it’s to do your Kegel exercises. It’s the standard recommendation, the default answer, the thing written on handouts and repeated in appointments. And for many women, it is genuinely useful advice.
But for some, it may be actively counterproductive. Some women have been doing their pelvic floor exercises diligently for months or years and their symptoms have not improved or have quietly got worse with no explanation why.
According to Dr Sandra Elmer, Urologist and Women’s Pelvic Specialist and part of the endota Wellbeing Conversation, the missing piece is almost always the same: the pelvic floor. Like any muscle group, the pelvic floor needs to be able to both contract and relax. When one side of that equation is neglected, the whole system suffers. Understanding which side needs attention is where the real work begins.
what does a healthy pelvic floor actually do?
A well-functioning pelvic floor contracts when it needs to, when you cough, lift, sneeze or exercise and fully relaxes when it doesn’t. It tightens to prevent leakage and relaxes completely to allow urination, bowel movements, intercourse and rest. Both movements are essential, neither works without the other.
Pelvic floor dysfunction symptoms arise when this coordination breaks down. And the breakdown can go in either direction: a pelvic floor that is too weak and cannot generate enough force when needed, or one that is too tight and cannot relax fully when it should. These are two distinct problems, they feel different in the body, they require different approaches and treating one with the solution for the other can cause real harm.
the case for strengthening: when kegels help
Pelvic floor weakness is a real and common issue. Childbirth, ageing and the decline of oestrogen levels that comes with perimenopause and menopause all affect the pelvic floor’s strength and support.¹ Dr Elmer notes that as oestrogen levels fall, the tissues of the pelvis, including the pelvic floor muscles, can become thinner and weaker, reducing their ability to do their job.
The signs that pelvic floor strengthening may be what’s needed include leakage when you cough, sneeze, laugh or exercise, a sense of heaviness or dragging in the pelvis, or reduced sensation. These are classic signs of a pelvic floor that isn’t generating sufficient support.
For this group, Kegel exercises for women, systematic pelvic floor muscle contractions done correctly and consistently, are an effective and evidence-supported tool.² Core strength also plays a supporting role, since the pelvic floor does not function in isolation but as part of a broader system that includes the deep abdominal muscles and the diaphragm. Building overall core stability helps the pelvic floor do its job more effectively.
the case for relaxation: when kegels make things worse
Here is the part most women are never told. For those with an overactive or hypertonic pelvic floor, doing more pelvic floor contractions does not help. It amplifies symptoms. More squeezing into an already tight system makes everything worse, and the women who experience this are often bewildered, having followed the advice they were given and found it didn’t work.
The signs of a hypertonic pelvic floor treatment need are different from those of weakness. Pain or discomfort during intercourse, a persistent urge to urinate or pain when urinating that has been investigated and found not to be a urinary tract infection, difficulty fully emptying the bowel and chronic, deep pelvic pain are all common presentations.⁴ As Dr Elmer describes it, it can feel “almost like having a tension headache in your pelvis.”
Stress is a major driver of this pattern. As covered in How Stress Affects Your Pelvic Floor, the pelvic floor is directly connected to the autonomic nervous system, and chronic stress can leave it in a state of persistent bracing. The solution for this group is not more contraction. It is pelvic floor relaxation through breathwork, gentle stretching, nervous system regulation and, where needed, targeted support from a pelvic floor physiotherapist.
Dr Elmer is direct: “If you’re really struggling or need some extra support, please find a specialist pelvic floor physiotherapist because they’re really good at teaching you ways that you can relax your pelvic floor and stop them from spasming.”
“If you’re really struggling or need some extra support, please find a specialist pelvic floor physiotherapist because they’re really good at teaching you ways that you can relax your pelvic floor"
exercise and the pelvic floor: finding the right balance
High-impact and high-load exercise is worth addressing specifically, because its relationship with the pelvic floor is more nuanced than most women are aware of. Dr Elmer explains that it can affect the pelvic floor in two distinct directions.
Activities that keep the pelvic floor constantly engaged, such as ballet, dancing or high-intensity training, can cause the muscles to become overactive over time.⁵ Heavy resistance training and high-load bearing exercises place downward pressure on the pelvic floor, which can stretch the ligaments and muscles that provide pelvic support. Neither of these is a reason to avoid exercise. It is a reason to be informed and, if symptoms arise, to get appropriate guidance.
Signs that exercise may be affecting pelvic floor function include leakage during high-impact activity such as running or jumping, a feeling of heaviness or bulging in the vagina during or after exercise, or pelvic pain that appears or worsens with certain movements. “Some of the signs women can look out for,” Dr Elmer says, “may be urinary leakage with rises in abdominal pressure such as coughing, exercise or bending over, or things that might tell you you have pelvic floor organ prolapse, so you’re starting to feel a bulge or heaviness in the vagina.”
For women with existing pelvic floor concerns, low-impact movement, pilates and supervised exercise with guidance from a pelvic floor physiotherapist on how to engage and protect the pelvic floor during activity are all worth considering. The goal is not less movement, it’s movement that works with the pelvic floor rather than against it.
so which one do you need?
The honest answer is that many women need a combination of both, and the balance can shift across life stages. A woman who needed strengthening in her 30s after childbirth may find she needs more focus on relaxation in her 40s as stress accumulates. Neither approach is permanent or fixed.
Rather than a checklist to diagnose yourself, think of the following as a way of noticing what your body might be telling you.
Signs that may point toward weakness:
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Leakage when coughing, sneezing or exercise
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A sense of heaviness or dragging in the pelvis
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Reduced sensation
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Symptoms that worsen with activity.
Signs that may point toward tension:
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Pain or discomfort with intercourse
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Persistent urinary urgency or pain when urinating with no infection found
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Difficulty fully emptying the bowel
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Chronic pelvic pain or aching
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Symptoms that worsen with Kegel exercises or high-stress periods.
This is a starting point for self-reflection, not a self-diagnosis. Pelvic floor dysfunction symptoms can overlap and present differently in different women and the most reliable way to understand exactly what’s happening is assessment by a pelvic floor physiotherapist. Dr Elmer is clear about this: for women doing pelvic floor exercises in Australia and elsewhere, a specialist assessment before self-prescribing is genuinely worth it. The Continence Foundation of Australia is a reliable resource for finding local practitioners.³
building a pelvic floor practice that works for you
A sustainable approach to pelvic floor health combines awareness, relaxation and strength in the right proportions for the individual. It is less a programme and more a relationship with this part of the body, one built on attention rather than obligation.
Breathwork is the foundation, giving the pelvic floor its natural opportunity to release with each breath cycle and supporting the nervous system shift that makes relaxation possible. This is explored in depth in How Breathwork Supports Pelvic Floor Relaxation, and it is a genuinely accessible starting point for any woman regardless of where she is in the tension-to-weakness spectrum.
Stress management is the ongoing commitment that underpins everything else. The endota Organic Relax Massage and Hot Stone Massage both support nervous system regulation in ways that benefit the pelvic floor indirectly, by creating the conditions in which tension can release and the body can restore its natural coordination. These are not targeted pelvic health interventions but they are a meaningful part of a lifestyle that consistently returns the body to ease. endota Retreat offers guided relaxation and body-awareness practices from home for those wanting to build this into their daily ritual.
frequently asked questions
how do I know if my pelvic floor is too tight or too weak?
Weakness tends to show up as leakage with physical activity or exertion, a sense of heaviness in the pelvis or reduced sensation. Tension tends to present as pain with intercourse, urinary urgency or pain when urinating without a UTI, difficulty emptying the bowel and chronic pelvic discomfort. Symptoms can overlap and a pelvic floor physiotherapist is the most reliable way to get a clear picture.
can kegel exercises make pelvic floor problems worse?
Yes, for women with a hypertonic or overactive pelvic floor. Kegel exercises involve contracting muscles that are already too tight, which can amplify symptoms including pain, urgency and discomfort. If Kegels have not helped or have made things worse, this is worth raising with a pelvic floor physiotherapist rather than continuing the same approach.⁴
what are the signs of a hypertonic (overactive) pelvic floor?
Common signs include pain during intercourse or with any kind of vaginal penetration, a persistent urge to urinate or pain when passing urine that is not caused by an infection, difficulty fully emptying the bowel and chronic pelvic pain or aching. Symptoms often worsen during stressful periods, which reflects the pelvic floor’s close connection to the autonomic nervous system.
does high-impact exercise affect the pelvic floor?
It can, in either direction. Activities that keep the pelvic floor constantly engaged may cause overactivity over time, while high-load exercises like heavy weights may place downward pressure that stresses, and stretches, pelvic support structures.⁵ This is not a reason to avoid exercise, but if symptoms appear during or after activity, it is worth getting guidance from a pelvic floor physiotherapist on how to exercise in a way that supports rather than strains the pelvic floor.
do I need to see a pelvic floor physiotherapist, or can I manage this myself?
For mild symptoms of a tight pelvic floor, self-management with breathwork, relaxation and gentle movement is a reasonable starting point. If you are experiencing symptoms of pelvic floor weakness, starting to do regular, gentle pelvic floor exercises can help. For anything persistent, confusing or significantly affecting quality of life, a pelvic floor physiotherapist is strongly recommended. They can identify exactly what is happening and guide a targeted approach, which is far more effective than guessing. Continence Health Australia can help locate practitioners across Australia and has excellent online resources and tools.³
how does stress affect pelvic floor function?
The pelvic floor is partly governed by the autonomic nervous system, which means the stress response directly affects its tension levels. Chronic stress can leave it in a state of persistent bracing, contributing to hypertonic pelvic floor dysfunction. This is covered in depth in How Stress Affects Your Pelvic Floor.
can massage or bodywork support pelvic floor health?
Indirectly, yes. Treatments that support the shift into a parasympathetic nervous system state, such as the endota Organic Relax Massage or Hot Stone Massage, create the conditions in which pelvic floor tension can release. They are not a clinical treatment for pelvic floor dysfunction but they are a meaningful part of a stress-management and nervous-system-regulation approach that benefits pelvic health over time.
references
¹DeLancey, J. O. L. (1994). Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. American Journal of Obstetrics and Gynecology, 170(6), 1713–1723. https://doi.org/10.1016/S0002-9378(94)70346-9
²Bø, K., & Sherburn, M. (2005). Evaluation of female pelvic-floor muscle function and strength. Physical Therapy, 85(3), 269–282. https://doi.org/10.1093/ptj/85.3.269
³Continence Foundation of Australia. (n.d.). Pelvic floor exercises. https://www.continence.org.au/bladder-bowel-health/pelvic-floor/pelvic-floor-exercises
⁴Faubion, S. S., Shuster, L. T., & Bharucha, A. E. (2012). Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clinic Proceedings, 87(2), 187–193. https://doi.org/10.1016/j.mayocp.2011.09.004
⁵Bø, K. (2004). Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Medicine, 34(7), 451–464. https://doi.org/10.2165/00007256-200434070-00004
Dr Sandra Elmer is a urologist and women’s pelvic specialist. She is part of the endota Wellbeing Conversation, a group of experts who share evidence-based insights to help people better understand how their bodies and minds work.
