Women everywhere seem to be well aware of a kegel exercise. This is a contraction of the pelvic floor muscles often used as a strengthening technique to help those with incontinence or pelvic organ prolapse. (Want to learn more? See my previous blog “What’s a Kegel Anyways?”). But what if you already have tight pelvic floor muscles? All too often women worry that their pelvic floor is too weak. However, a great deal of my time is spent relaxing, stretching and lengthening shortened pelvic floor muscles. For this group of people, performing unnecessary kegel exercises can create or worsen problems.

Technically, a shortened or tight muscle is said to be in hypertonicity, or a relatively constant state of increased activation. In lay term, these people are unnecessarily contracting their pelvic floor muscles for a large part of their day. Usually this is unintentional. Just like someone can carry tension in their shoulders, you can carry tension in your pelvic floor. And just like shoulder tension can cause tension headaches, pelvic floor tension can cause pelvic pain.

So how does someone develop hypertonicity in their pelvic floor? There are many reasons why this could happen. Many women walk around all day trying to “suck in”, pulling their pelvic floors up along with their abdomens. Sometimes sports that depend on a lot of inner thigh strength (ballet, skating, gymnastics, horseback riding, swimming) can promote increased muscle tone of the pelvic floor. There are plenty examples of people who have obsessively done “core exercises” to the point of causing pelvic floor hypertonicity. A bad injury to the tailbone can alter the muscle tone of the pelvic area. People who suffer with pre-existing abdomino-pelvic conditions (irritable bowel syndrome, endometriosis, chronic prostatitis) often hold themselves in a curled/fetal position that can create hypertonicity of the pelvic floor. The inability to empty the bladder completely can cause the pelvic floor to have trouble relaxing. The list goes on and on…

Why is pelvic floor hypertonicity so bad? Constantly using your kegel muscles, even to a mild degree, can lead to muscle strain, muscle fatigue, muscle pain, discomfort with exercise, and painful sexual intercourse. It can also contribute to muscle “knots” or trigger points. These are small parts of a hypertonic muscle that have a difficult time relaxing and are tender to the touch. Sometimes a tight pelvic floor can make it difficult to completely empty the bladder, or initiate a urine stream and even contribute to constipation. Finally, holding your muscles in a shortened and tight position can actually lead to weakness. Because the muscle doesn’t relax fully, it never really gets the opportunity to squeeze fully. It just kind of stays on, to a small degree, most of the time, never really relaxing and never really being well used. For this reason, I sometimes see people who have a hypertonic pelvic floor that is also weak and causes incontinence.

So how can you tell if you have hypertonicity of the pelvic floor? Often times pain in or around the genitals or low abdomen is a good indicator. Pain in the vagina or rectum, pain near the tailbone, and pain around the bladder can all be signs of hypertonicity. Difficulty emptying the bowel or bladder can also be a sign. Urinary incontinence, especially associated with a strong urge to go, can sometimes be a sign. If you are never really emptying the bladder fully, the bladder will not relax and the pelvic floor will continue to contract so as not to leak. It can be a vicious cycle.

What can be done about a hypertonic pelvic floor? Most importantly, you need to learn how to relax the muscle! This sounds easy, but I can assure you that is rarely the case. If you’ve been living with a shortened pelvic floor muscle for years, this becomes your new normal and learning how to let it go can feel quite odd. The best way that I can describe a relaxed pelvic floor is by bringing to mind the instant during a bowel movement just before you push. The muscles are relaxed but you haven’t actually applied any abdominal pressure. For some, they learn best by the verbal cue of “drop your pelvic floor”, or “let go of your kegel”. Many times I need to apply some manual pressure externally or internally to demonstrate what a relaxed pelvic floor feels like. Sometimes massage techniques are used to get rid of muscle knots and trigger points. Frequently internal and external stretches need to be done.

Sometimes I need to use a biofeedback machine to help someone “see” a relaxed muscle. Biofeedback is the use of internal or external electrodes placed on the pelvic floor muscles. These electrodes work in a very similar way to an ECG heart monitor, though instead of picking up heart muscle activity, they collect information about pelvic floor muscle activity. This muscle activity is captured on a computer screen so you and the physiotherapist can visualize how the muscles might be working. The goal would be to see minimal muscle activity on the screen.

There always seems to be a “light bulb moment” where the person will finally understand what a relaxed pelvic floor is. “OOOOOOHHHHHH – you mean my muscle is supposed to be like this most of the day?” Learning how to keep the muscle from sneaking back up into its hypertonic position is another challenge of treatment.

All of this being said, you can see why someone who has no idea how to relax their pelvic floor should not be working on activating it even more with a kegel exercise! Sometimes learning how to “un-kegel” or reverse kegel is the best course of action. Unsure if you have a hypertonic pelvic floor that could be contributing to a condition? Speak to your family doctor or healthcare provider about finding a well trained pelvic floor physiotherapist that can assess the pelvic floor and develop a treatment plan designed just for you.

Katie Kelly,
BSc., MSc. PT