If you've ever mentioned pelvic pain, bladder urgency, or discomfort during sex to a doctor, there's a good chance you heard some version of the same advice: "Do your Kegels." It's one of the most commonly prescribed exercises in women's health. It's also, for a significant number of people, exactly the wrong thing to do.

Understanding why requires a basic grasp of how the pelvic floor actually works, something most people never learn, even after years of dealing with pelvic health issues.

What the Pelvic Floor Actually Is

The pelvic floor is a group of muscles, ligaments, and connective tissue spanning the base of your pelvis like a hammock. These muscles support your bladder, uterus, and rectum. They help control urination and bowel movements, contribute to sexual function, and stabilize your core. When they're working well, you never think about them. When they're not, the effects can be far-reaching and deeply disruptive.

Pelvic floor dysfunction generally falls into two categories, and the distinction matters enormously for treatment.

Hypertonic vs. Hypotonic: Why It Matters

Hypotonic (underactive) pelvic floor means the muscles are weak or lax. Symptoms typically include urinary incontinence (leaking when you cough, sneeze, or exercise), a feeling of heaviness or pressure in the pelvis, and reduced bowel control. For this presentation, Kegel exercises, which strengthen the pelvic floor through contraction, are appropriate and often effective.

Hypertonic (overactive) pelvic floor is the opposite. The muscles are too tight, stuck in a state of chronic tension, and unable to fully relax. Symptoms include pelvic pain, urinary urgency and frequency, difficulty emptying the bladder, constipation, and pain during intercourse. About 1 in 10 people experience hypertonic pelvic floor dysfunction [StatPearls, Pelvic Floor Dysfunction, 2023]. For this presentation, Kegels can make things significantly worse, you're essentially asking an already clenched muscle to clench harder.

The AUA guidelines for interstitial cystitis specifically state that pelvic floor strengthening exercises (including Kegels) should be avoided in IC patients, and that pelvic floor physical therapy focused on relaxation should be offered instead [Clemens et al., AUA Guideline, 2022]. This is a Grade A recommendation, their highest level of evidence.

Why This Gets Missed

Most primary care providers and even many OB/GYNs receive limited training on pelvic floor assessment. The default advice of "do Kegels" assumes a hypotonic presentation without confirming it. A systematic review in Sexual Medicine Reviews examining pelvic floor physical therapy for hypertonicity found that while evidence supports PT-based treatment, the condition remains underdiagnosed because it requires specialized internal assessment that many providers don't perform [Meister et al., 2022].

If you've been doing Kegels and your symptoms haven't improved, or have gotten worse, this could be why.

What Pelvic Floor PT Actually Looks Like

Pelvic floor physical therapy is not just "doing exercises." A trained pelvic floor therapist performs an internal and external assessment to evaluate muscle tone, identify trigger points, and determine whether your pelvic floor is overactive, underactive, or a combination (which is common, it exists on a spectrum).

Treatment for a hypertonic pelvic floor typically includes manual therapy (internal and external soft tissue release), diaphragmatic breathing exercises to promote pelvic floor relaxation, biofeedback to help you learn what relaxation actually feels like, and education around posture, stress management, and movement patterns that contribute to tension.

For hypotonic presentations, therapy may include progressive strengthening, electrical stimulation, and functional training.

How to Find the Right Provider

Look for a physical therapist with specialized training in pelvic health. Certifications like the WCS (Women's Health Clinical Specialist) or PRPC (Pelvic Rehabilitation Practitioner Certification) indicate advanced expertise. Ask whether they perform internal assessments, because without one, a true evaluation of pelvic floor tone isn't possible.

You deserve a provider who assesses before they prescribe. Your pelvic floor is more complex than one exercise can address.

If pelvic floor PT isn't accessible right now.

Pelvic floor physical therapy is the gold standard, but it's not always accessible. Sessions can run $150 to $300 out of pocket, not every insurance plan covers it, and depending on where you live, the nearest specialist might be hours away.

If PT isn't an option for you right now, there are still things you can do:

• Check your insurance. Many plans cover pelvic floor PT with a referral, even if it's not obvious on the benefits page. Call your insurance directly and ask about coverage for "physical therapy for pelvic floor dysfunction." Some plans require a specific diagnosis code from your provider.

• Ask about sliding scale. Some PT clinics offer reduced rates for uninsured or underinsured patients. It's worth asking even if it's not advertised.

• Look into telehealth options. Virtual pelvic floor PT has become more widely available and is often more affordable. It won't include internal work, but a good telehealth PT can guide you through breathing techniques, relaxation exercises, and movement strategies.

• Start with diaphragmatic breathing. If your pelvic floor is hypertonic, learning to breathe deeply into your belly and ribcage (rather than shallow chest breathing) is one of the most effective things you can do on your own. It's the foundation of most pelvic floor relaxation programs.

• Avoid self-prescribing Kegels. If you haven't been assessed, doing nothing is safer than doing the wrong exercise. This is especially true if your symptoms include pain, urgency, or tightness.

Lack of access doesn't mean lack of options. But it does mean being intentional about what you try on your own, and continuing to push for coverage or referrals when you can.

Sources

Clemens, J.Q., et al. "Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome." Journal of Urology, AUA Guideline, 2022.

StatPearls. "Pelvic Floor Dysfunction." National Library of Medicine, updated June 2023.

Meister, M.R., et al. "Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy." Sexual Medicine Reviews, 10(2), 2022.