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Nobody Warned US
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A muscle group nobody taught you existed — until it hurt.

Pelvic floor dysfunction

The pelvic floor is a bowl of muscle, fascia, and nerves that holds bladder, uterus, and rectum, and has to both contract and fully relax. Dysfunction is not one thing: the floor can be too tight, too weak, poorly timed, or all three in different layers.

What it is

  • Hypertonic (high-tone) floors are clenched, short, and tender. They are common in endometriosis, IC/BPS, vulvodynia, and after years of guarding pain. They cause pain, urgency, and emptying problems — the opposite of what Kegels fix.
  • Hypotonic (low-tone) floors are under-recruited. They contribute to stress incontinence and some forms of pelvic organ prolapse. Strengthening has a role here — after someone has actually assessed you.
  • You can have a tight, painful superficial layer and a poorly supportive deep layer at the same time. That is how IC-type urgency and a grade 1 prolapse can share a pelvis.
  • Endometriosis lesions and bladder inflammation make the floor guard. The guarding then becomes a second disease. This is why excision or bladder treatment alone can disappoint if the floor is never retrained.

What it can feel like

  • A golf-ball, tailbone, or “sitting on a bruise” sensation
  • Pain with sex, tampons, or a speculum that gets called “just tense”
  • Hesitancy, spraying, or incomplete emptying of bladder or bowel
  • Constipation that needs splinting (pressing on the vagina or perineum)
  • Hip, low-back, or groin pain that ordinary PT never quite reaches

What you were probably told

  • “Just do your Kegels.”
  • “That’s in your head. Relax.”
  • “Everyone is a little tight down there.”
  • “If you can have a baby, your floor is fine.”

How it actually gets named

  • Internal and external pelvic floor exam by a trained clinician or pelvic PT: tone, tenderness, trigger points, coordination, and descent with strain.
  • Not a Kegel app. Not a one-minute “squeeze for me” at a well-woman visit.
  • Anorectal manometry, defecography, or uroflow when emptying is the main complaint.
  • Screen for the conditions that keep the floor clenched: endo, IC, fissures, chronic constipation, trauma, anxiety with a somatic loop.

What tends to help

  • Pelvic floor physical therapy with someone who treats pain, not only postpartum leaks. Look for CAPP, PRPC, or Herman & Wallace training.
  • Down-training, diaphragmatic breathing, manual release, hip and thoracic mobility — then strengthening if you actually need it.
  • AUA grade A: manual PT for IC/BPS with pelvic floor tenderness. Explicitly avoid Kegels in that setting.
  • Treat the driver: bowel regimen for straining, endo care for cyclical guarding, bladder strategies for IC flares.
  • Pessary, dilators, or vaginal estrogen (when appropriate) as adjuncts — not as the whole plan.

Take these into the room

  • Is my pelvic floor high-tone, low-tone, or mixed — and how do you know?
  • Are you recommending Kegels, or have you felt the muscles?
  • Can you refer me to a pelvic PT before we talk surgery or more meds?
  • If I have both pain and a small prolapse, which do we treat first?