Meet The Pelvic Floor

What Is The Pelvic Floor?

The clitoris. The penis. The vagina. When it comes to reproductive anatomy and sexual health, there are some obvious major players. But the unsung hero of your lower body may just be the pelvic floor, which supports bladder function, childbirth, erections, orgasms—and more!

The pelvic floor is a group of muscles in the pelvis that sit in a sling shape between the pubic bone at the front of the pelvis and the tailbone at the back. These muscles support the organs inside the pelvis including the bladder and bowel, as well as the uterus (for people who have one).

These muscles wrap around the urethra, anus, and vagina, controlling the opening and closing of these passages. This muscle group also connects to the shaft of the penis and includes the levator ani, ischiocavernosus, bulbospongiosus, and coccygeus muscles.

While this may not sound exciting, having a healthy pelvic floor is critical for sexual function, pregnancy, childbirth, peeing, and pooping. When the pelvic floor is healthy, these processes run smoothly, but when the pelvic floor isn't healthy, there can be issues.

Signs that pelvic floor problems may be affecting your sex life:

• Difficulty having an orgasm
• Difficulty getting and maintaining an erection (erectile dysfunction)
• Premature ejaculation
• Pain during sex
• Difficulty with vaginal or anal penetration

Other symptoms of pelvic floor issues:

• Accidentally peeing (urinary incontinence)
• Accidentally pooping (fecal incontinence)
• Having trouble emptying the bladder
• Constipation
• Lower back and pelvic pain
• Spine, abdominal, pelvic girdle, and genital pain

It’s also important to know that everyone has a pelvic floor—regardless of gender, age, or body type. As a lot of information surrounding the pelvic floor relates to people who’ve given birth, there’s a misconception that only people with vulvas have one, but in fact, the pelvic floor plays an integral role in every body.

The Pelvic Floor And Sex

Having a healthy pelvic floor can improve your sex life. However, a healthy pelvic floor does not mean a “tight” pelvic floor. Some people have the mistaken idea that having a pelvic floor that’s “tight” means having a tighter vagina and better sex. But to function properly, the pelvic floor has to be able to both squeeze and relax. A pelvic floor that’s too tight can cause pain during sex, difficulty getting or maintaining erections, and premature ejaculation.

The pelvic floor also plays a critical role in orgasms; they are, in fact, the muscles that rhythmically contract as part of these delightful pleasure spasms. This means that when the pelvic floor muscles can tighten and relax easily, you’re both more likely to orgasm, and to have more control over your big-Os.

Pain During Sex

A pelvic floor that is overly weak or overly tight can cause pain during sex, especially during penetration. A healthy pelvic floor will reduce your chances of experiencing this kind of discomfort.

Nearly three in four women experience painful sex at some point in their lives. While it is more common among people with vaginas, people of any gender and genitals can experience dyspareunia (the technical word for painful sex). Although some pain and discomfort is common, it's not a normal part of sex. Pain is a sign that something is wrong and needs your attention, whether that means applying more lube, changing positions, or going to see a doctor.

There are a number of possible causes of pain, including infection, lack of lubrication, lack of arousal, tight foreskin, cervix sensitivity, and more. Below are several common pain issues related specifically to your pelvic floor muscles.

Vaginismus

Vaginismus is a condition where the muscles tighten, causing vaginal pain with initial and deeper penetration. When anything is inserted into the vagina, whether a tampon, finger, or penis, the muscles spasm painfully. For some people, the condition may be so severe that vaginal penetration is not possible. Vaginismus is often (but not always) due to past damage or trauma, such as previous painful sex or sexual assault. Some people find that applying a hot compress to the vulva before and after sex can help the muscles to relax. Certain stretches and breathing exercises may also alleviate pain. If you think you may have vaginismus, the best idea is to go see a doctor and or a pelvic health physical therapist for professional help.

Although many people experience it at some point, pain is not a normal part of sex. - Dr. Ossai

Gender Confirmation Surgeries

Transgender people who undergo genital surgeries to affirm their gender may experience pain during sex after their surgery. Scar tissue may be the cause, or it could be due to the pelvic muscles being cut or moved during the surgery and needing to be retrained. Another possibility is that underlying pelvic floor issues are interfering with a full recovery from the operation.

Hormones

Both the hormonal changes that occur during menopause and while taking testosterone as part of a gender transition can cause the walls of the vagina to thin and weaken, which can contribute to pain and discomfort during sex. Severe pelvic floor weakness, often appearing in older age, can lead to uterine prolapse (when the uterus falls into the vaginal passage), which can also make penetrative sex painful.

Anal Sex Pain

Overly tight pelvic floor muscles can make anal penetration painful. It’s not uncommon for anal play to feel a bit unfamiliar or slightly uncomfortable at first, but pain is neither a normal or necessary part of anal sex. If the muscles are not ready, trying to insert a penis or dildo into the anus can cause them to spasm painfully. To prevent this, start with a finger or small butt plug, take plenty of time, breathe deeply with your belly, and use lots of lube. The parasympathetic nervous system controls the internal anal sphincter muscle, which you can’t consciously control, so you want to make sure that you’re very relaxed, otherwise that muscle will stay tight.

Ways To Reduce Pain During Sex

If you are experiencing pain during sex, you should see a health care provider. If the discomfort is minimal, you can experiment with sex positions where penetration isn’t too deep, or have fun with external stimulation. There are also some tools and toys that can ease sex-related pelvic floor pain. The OhNut is a squishy ring that you put on the shaft of a penis. It lets you add layers to control the depth of penetration. Some people also use ice or heating packs on their vulvas to prepare for or relax after sex. But be sure to frequently check your skin when using ice and heat, as they can both burn you.

I had spent six grueling years in chronic pain, stuffed full of mind and body crushing medication, but on that day Dr. Balenciaga Boots looked me right in the eyes and she said, 'My dear, what you have is shockingly common. It’s called pelvic floor dysfunction ... We can fix you with simple physical therapy.' - Zosia Mamet, actress

Orgasms And The Pelvic Floor

What does the pelvic floor have to do with orgasm? The answer is A LOT. An orgasm is actually a series of muscle contractions triggered by the pelvic floor. During sexual stimulation, arousal builds and muscle tension increases; this tension is eventually released with rhythmic contractions.

When the pelvic floor muscles are too weak, achieving orgasm becomes difficult as they lack the strength to tense and release as needed. When the muscles are stronger you can squeeze them to intensify sensation and they will be ready to pulse with the contractions of orgasm when the time comes.

On the other hand, when the muscles are overly tight you can have difficulty controlling orgasm, achieving an orgasm, or may orgasm more quickly than you’d like. A tight pelvic floor can also be the underlying reason for premature ejaculation.

Causes Of Erectile Dysfunction

The pelvic floor plays an important role in achieving and maintaining an erection, and can be a contributing cause of erectile dysfunction. For the penis to become erect, the pelvic floor muscles need to relax enough to let blood flow into the penis and make it hard. Likewise, to maintain an erection the muscles need to be strong enough to keep the blood inside and prevent it from flowing back into the rest of the body. When pelvic floor muscles are not contracting and relaxing properly, Kegel exercises have been shown effective for improving erectile function.

Not being able to create or maintain an erection can be due to a number of physical factors, such as diabetes, certain medications, and heart conditions. Psychological factors like performance anxiety, stress, and relationship troubles can also be behind erection issues. So, pelvic floor problems are not always at play, but they may be.

Premature And Delayed Ejaculation

Pelvic floor issues, especially muscle tightness, can be an underlying factor with premature ejaculation as well. While various physical and psychological factors often contribute, studies show that learning to control and relax pelvic floor muscles can help people delay ejaculation. Using breathing exercises and taking pauses during masturbation or partnered sex may help to relax the muscles and delay ejaculation.

Pelvic floor problems may also be why people experience delayed ejaculation. In contrast to premature ejaculation, this is when it takes much longer than you would like to reach climax. Again, stretches and Kegel exercises may help to develop pelvic floor muscle tone and better control over the muscles, which can alleviate the frustrations of delayed ejaculation.

The Pelvic Floor After Childbirth

The pelvic floor plays a huge role in pregnancy and childbirth. First, the pelvic floor muscles support the uterus and growing fetus during pregnancy, carrying a significant amount of weight by the time the baby is full-term. Then, during vaginal childbirth the muscles do a lot of work stretching to make room for the baby. In the process, some tearing is possible, and if it’s a difficult delivery the muscles may be damaged by the use of forceps or other medical interventions.

Hormones also soften the pelvic floor muscles and ligaments during pregnancy. Therefore, regardless of whether the baby is delivered through vaginal birth, c-section, or if there is a late-term miscarriage, pelvic floor muscles are often notably weakened after pregnancy—both from hormones, and the pressure on the muscles from carrying the fetus.

After pregnancy and childbirth it is common to experience symptoms of a weakened pelvic floor, such as peeing a little when you sneeze (also known as urinary incontinence). Doing Kegels before, during, and after pregnancy can help with pelvic floor strength and health. Seeing a pelvic floor physical therapist can also help if these symptoms are troubling you.

After childbirth it is important to give your body the time and rest it needs to regain muscle tone. Try not to rush too quickly into doing Kegel exercises or penetrative sex. How long it takes to regain pelvic floor strength depends on a range of factors such as age, the condition of your pelvic floor before you gave birth, and whether there were cuts or tears sustained during delivery. Scar tissue from birthing (c-section or vaginal delivery) can also cause pain during intercourse. Talk to your doctor about getting help from a pelvic health physical therapist for postpartum rehabilitation.

Peeing During Sex

Are you peeing yourself accidentally during sex? You’re not alone. Accidentally peeing during sex (the technical term is coital urinary incontinence) is not uncommon, but it is a sign that something isn’t going quite right with your bladder or pelvic muscles. Coital urinary incontinence can be embarrassing, frustrating, and make sex less enjoyable.

So, what exactly is happening when you accidentally pee during sex? One possible cause is the bladder releasing when it’s not supposed to, due to an infection or irritation from scar tissue. Or, coital urinary incontinence may be due to weakened pelvic floor muscles that accidentally release during sexual activity.

Working on your pelvic floor strength by doing Kegels will help with bladder control during sex if a weakened pelvic floor is the cause. You can also reduce the inconvenience by putting down towels, a waterproof picnic blanket, or purchasing a sexy Fascinator Throe.

There’s also a chance you could be squirting, not peeing. It's easy to confuse the two; some people may feel anxious that they are peeing, when they are actually squirting!

Kegel Exercises And Pelvic Floor Stretches

Like all muscles, you want to strengthen AND stretch your pelvic floor. Doing so will help avoid pain during sex, keep the bladder and bowels functioning correctly, and maximize sexual pleasure. Lotus pose and deep diaphragmatic breathing are great techniques for everyone, especially if you're feeling tight. Check out this article on how to properly stretch, relax and lengthen your pelvic floor.

Kegels are pelvic floor exercises designed to strengthen and tone the muscles. They’re basically like going to the gym—but for your pelvic floor. Before you dive in, it’s important to know that they’re not suitable for everyone. If you have a healthy or weakened pelvic floor, Kegels can maintain and strengthen muscle tone. On the other hand, if you have an overly tight pelvic floor, Kegels can further tighten the muscles and make your pelvic issues worse. If you think you may have tight pelvic muscles, consult a pelvic floor physical therapist before trying these exercises. Check out this article that explains proper Kegel technique.

Are Kegels only good for vaginal health? No! Kegels are for people of all genders and bodies. Doing regular Kegel exercises helps keep your bladder, bowel, and sexual organs functioning properly no matter what genitals you have. For people with penises, Kegels can help with erectile issues or recovery of sexual function after prostate cancer.

Seeing A Care Provider About Your Pelvic Floor

If you have symptoms of a weak or tight pelvic floor that are bothering you it’s a good idea to see a doctor to get a correct diagnosis and the tools you need to keep your pelvic health on track. You can start by seeing your regular physician, who may refer you to a pelvic floor physical therapist or a urologist for further treatment. You can also look up a specialist near you on the Pelvic Rehab database.

Do You Need To See A Health Specialist About Your Pelvic Floor?

Ask yourself these questions:

• Do I have pain during penetrative vaginal or anal sex that’s beyond the occasional lack of lubrication?
• Do I constantly ejaculate before I’m ready?
• Do I have a hard time maintaining an erection?
• Am I or was I pregnant?
• Am I peeing myself during sex?

It can be hard to find the right care provider for your sexual needs. You want someone you can talk freely with, who will take your concerns seriously, and who will offer solutions. If you are feeling dismissed or unsatisfied with the suggested treatments you may want to find a doctor who is more sympathetic to your concerns and who has more knowledge of pelvic floor health and treatments.

Talking To Your Doctor

Day to day we don’t get much practice talking about intimate issues like pelvic floor health and sexual function so it can feel overwhelming or embarrassing to talk to a medical professional about these issues. Check out these conversation starters to prepare you for talking to your doctor.

I love it when my patients ask me directly, because that gives me so much more information into their health and well-being. - Dr. Ossai

Sample Conversation: Accidentally Peeing During Sex

Pelvic floor physical therapist: What brings you in today?

You: I’m still peeing myself during sex. It started two years ago, after the birth of my son. It’s so embarrassing. I’ve had to buy a new mattress and I’m tired of washing our sheets.

Pelvic floor physical therapist: This is not uncommon, but it’s also not normal. Let’s have a look and see what’s going on.

Sample Conversation: Pain With Penetration

Doctor: Ok, your exam looks good. Take care.

You: Actually, I want to talk about one more thing. I’ve noticed increased pain during sex. When my boyfriend enters me, it makes me wince.

Doctor: Well, you don’t have an infection. Just make sure you relax and try some lube.

You: I have tried those things. It feels like stabbing pain whenever my boyfriend tries to enter me. This kind of pain started last year when I was dating a pretty terrible person. The pain is getting worse and it’s giving me anxiety. What kind of specialist should I see?

Doctor: It could be vaginismus—a condition where the pelvic muscles are too tight and spasm, causing pain with penetration. I’d recommend a pelvic floor physical therapist and a psychologist since vaginismus is often both physical and psychological.

Sample Conversation: Erectile Dysfunction

Nurse: The physical therapist will see you soon. Can you fill out this form and list any changes to your health?

You write: I’ve been experiencing some difficulty maintaining erections.

Physical therapist: Thanks for telling me about this! What’s going on?

You: A year ago I started having a hard time maintaining erections. It’s making me really anxious about sex. I get super turned on, but I can’t stay firm. It’s worse after I work out a lot. I read about Kegels, so I’m doing them all the time.

Physical therapist: There could be a few reasons for what's happening. Your muscles might be too tight, and not letting blood into the penis. I’m going to recommend a physical therapist for you.

What To Tell Your Doctor About Your Pelvic Floor Symptoms

To avoid forgetting any details, write up a list of symptoms beforehand. Include things that trigger the pain or dysfunction, indicate if this is new or a long term experience, and if you think it’s physical, psychological or both. It’s normal to feel uncomfortable, so remember that these are just body parts, and there is nothing to be embarrassed about. Your doctor has seen a lot. They also probably won’t ask about your sexual health, so you may have to bring it up.

Copy and paste this list in your phone ahead of your appointment:

• What kind of problems are you experiencing?
• What does it feel like?
• How frequent is it?
• Is this something new or life-long?
• Is it all the time or situational?
• Is it just physical, or is there a psychological component?
• What impact it is having on your life?
• List things you’ve tried to fix the problem.

Dr. Ossai (aka Dr. UC) is an assistant professor at the University of Texas Austin and manages the pelvic health program. She is also a certified sex counselor through the American Association of Sexuality Educators, Counselors and Therapists (AASECT). Dr. Ossai supports the University of Michigan’s sexual health certification program as an adjunct professor. Her clinical and research work focuses on pelvic floor dysfunction for marginalized communities, particularly women of color and the LGBTQIA community.