What the pelvic floor is and how it is assessed

Short answer: The pelvic floor is a layer of muscle and connective tissue that closes the lower opening of the pelvis like a hammock, and it supports the bladder, the uterus and the last part of the bowel from below. It is not always weak; it can also be too tight to release, and the work that follows differs between those two pictures. An assessment does not have to begin with an internal examination. If an internal assessment is going to be carried out, it is explained beforehand, consent is asked for, and it is not done if the woman does not want it.

Where the pelvic floor sits and what it looks like

The pelvis is a bony frame that is open at the bottom. The pelvic floor is the structure that closes that opening from below. It attaches to the pubic bone at the front, to the tailbone (coccyx) at the back, and to the two sitting bones at either side. Those two firm points that take your weight when you sit down mark the side edges of the floor. The whole area is roughly the size of the palm of a hand, and it is built from several layers of muscle stacked on top of one another.

The deepest layer is called the levator ani, the main lifting group of the pelvic floor. This is the layer that carries most of the weight of the organs above it. The more superficial layers contain the ring-shaped closing muscles (sphincters) around the urethra and the anus, together with muscles that take part in sexual function. Three openings pass through the layers: the urethra, the vagina and the anus. The muscles have to keep all three shut when they need to be shut and let them open when they need to open.

A contraction cannot be seen from the outside. When the movement is made as intended, the area around those three openings draws inwards and upwards in a short movement and is then fully released. A feeling of pushing down, or the abdomen bulging forwards, means the movement is running in the opposite direction.

What the pelvic floor does

The pelvic floor has four main jobs, and none of them works in isolation from the others. Between them they cover support of the organs, holding urine and stool, sexual function, and the management of abdominal pressure alongside breathing.

• Support: the bladder and the uterus rest on this layer, and so does the last part of the bowel. When support drops, a sensation of downward pressure or of something bulging can appear.
• Closure: the closing muscles that keep urine and stool from escaping sit here. In the moments when pressure rises suddenly, such as coughing, sneezing, laughing and jumping, these muscles have to respond in time.
• Sexual function: the muscles of the area play a part in arousal, sensation and the experience of pain. A pelvic floor that cannot release may be found alongside pain during intercourse. Pain of this kind has more than one possible cause, and working out which one applies belongs to a physician.
• Trunk support and pressure management: the pelvic floor works together with the diaphragm, which is the main breathing muscle, the deep abdominal muscles and the muscles of the lower back, and it contributes to the stability of the trunk under load.

Urinary incontinence is usually connected to one of these jobs, but which one comes to the front differs from woman to woman. That is why all four are considered together during an assessment. Leaking does not always come from a weak muscle. A muscle can be strong enough to contract well and still fail to answer a rise in abdominal pressure in time, and that too can lead to leaking. These two possibilities are looked at separately.

Breathing, abdominal pressure and the pelvic floor

The middle of the body can be pictured as a box that is closed at the top and at the bottom. The diaphragm forms the lid, the pelvic floor forms the base, the abdominal muscles close the front and the sides, and the spine with the muscles of the lower back closes the back. As you breathe in, the diaphragm descends, the contents of the abdomen are pushed downwards, and the pelvic floor lengthens a little. As you breathe out, it draws back up. Holding your breath while you try to contract the muscle therefore works against the very contraction you are trying to produce.

Coughing, sneezing, lifting something heavy and straining on the toilet all raise abdominal pressure quickly. When pressure rises, part of the load presses downwards onto the pelvic floor. If the muscle can meet that rise in time, no leaking happens. When the response is late, or when the muscle cannot meet the load, urine can escape. Pelvic floor work is therefore more than a set of contractions performed lying on your back. Learning to tighten the muscle just before a cough is as much a part of it as the exercises themselves.

Why pregnancy and birth load the pelvic floor

Pregnancy places a load on this area that lasts for months, while birth produces a short but intense stretch. The load in pregnancy works in two ways. The first is duration, since the weight of the growing uterus sits on the same layer month after month. The second is a change in the tissues. Connective tissue becomes more elastic in pregnancy, the abdominal wall lengthens, the centre of gravity moves forwards, and the way load is distributed through the pelvis changes. In some women urinary incontinence begins before the birth, in the later months of pregnancy, and that is linked to this increasing load.

In a vaginal birth the pelvic floor muscles and the nerves around them undergo a marked stretch over a short period. A long second stage, which is the pushing stage of labour, the use of forceps (a tong-shaped instrument used to help the baby out) or a vacuum (a suction cup applied to the baby's head), an episiotomy (a cut made during the birth) or a tear that happens on its own, and a large baby are among the circumstances that increase that stretch.

A caesarean birth does not spare the pelvic floor the load that builds up over the pregnancy, because much of that load forms in the months before the birth. The two modes of birth do not load the area in the same way, though: in a vaginal birth the muscles and the nerves around them are stretched directly as well. A caesarean is at the same time surgery through the abdominal wall, and its healing timetable runs differently from that of a vaginal birth.

Pregnancy and birth are not experienced in the same way by every woman. Some of the women reading this page will have had a difficult birth, and some will have had a pregnancy that ended in loss. What is written here describes the load that forms in the body, whatever the outcome of the pregnancy was.

A muscle can be too tight as well as too weak

Pelvic floor complaints are often summed up in one sentence: the muscles have weakened. The picture is wider than that. A muscle can indeed be too weak to contract properly, but the opposite happens as well. There is such a thing as a pelvic floor that cannot let go even at rest and sits at a constant level of tension. Telling these apart is a matter for clinical assessment, and the evidence summarised further down this page comes from studies of pelvic floor muscle training, which do not address the over-tight picture directly.

Symptoms reported with an over-tight pelvic floor include pain during intercourse, difficulty using a tampon, difficulty starting the flow of urine, an urge that returns shortly after leaving the toilet, a feeling that the bladder has not emptied fully, constipation, and pain in the tailbone and the pelvic region. In this picture, doing more contraction work can make the complaint worse. Several different conditions can produce these symptoms, and telling them apart is the physician's assessment rather than the physiotherapist's.

From the outside the two pictures can look similar, because leaking can occur in both. What separates them is the state of the muscle at rest, together with its capacity to contract and to release. This is why an exercise programme is not written before it is understood which picture is present. Where the pelvic floor is over-tight, the work opens with release, breathing and measures that reduce tension, and strengthening comes at a later step.

Which symptoms may involve the pelvic floor

The symptoms that can involve the pelvic floor are listed below. A woman who does not find her own situation on the list may still benefit from an assessment.

• Leaking urine when coughing, sneezing, laughing, jumping or lifting a weight.
• A sudden urge that cannot be held back, not reaching the toilet in time, getting up several times at night.
• Leaking wind, leaking stool, or staining of underwear.
• A feeling of downward pressure, fullness or bulging. This sensation usually increases at the end of the day and after long days spent on your feet.
• Pain during intercourse, dryness, or burning at entry.
• Tenderness, tightness or discomfort on touch where an episiotomy or a tear was stitched.
• Numbness, a pulling sensation, or altered feeling around a caesarean scar.
• Tailbone, groin and lower back pain that carries on after the birth.
• A bulge or a dip appearing along the midline of the abdomen under load.

Urinary incontinence after birth is common and affects roughly one woman in three. How common it is does not make it something to accept, and leaking should not be expected to disappear completely on its own. "Everyone who gives birth has this, you get used to it" is not an assessment.

Why Kegel exercises alone are not counted as the answer

Kegel is the name given to contracting and releasing the pelvic floor muscles voluntarily. Online it is usually described with a single instruction: squeeze, count, let go. The sentence that comes up most often afterwards is some version of "I have been doing this for months and nothing has changed." The weak point of the instruction is that nobody has checked whether the woman has found the right muscle. Nobody can tell by looking whether the right muscle is doing the work. So in a woman who has worked at it for a long time and seen no change, the first thing to look at is whether the movement is being done as intended.

Five problems come up again and again when women describe how they have been doing their Kegels.

• The wrong muscle working: while the buttock, inner thigh or abdominal muscles contract, the pelvic floor either stays still or is pushed downwards. Pushing down is a mistake that can increase leaking.
• Holding the breath: when the breath is held during the contraction, abdominal pressure rises and the exercise pushes in the opposite direction to the one intended.
• Never practising the release: releasing is learned just as contracting is. In a programme built only on squeezing, existing tension can increase.
• No progression: if the number of repetitions, the length of the contraction, the rest interval and the position never change, the work stalls. Being able to contract lying down does not mean the same contraction can be produced standing and under load.
• Nothing carried into daily life: the moment leaking happens is usually a cough, lifting the baby or climbing the stairs. The work has to be tied to those moments.

Not being able to feel the muscle at all is also common, and on its own it is a meaningful finding. It changes where the work begins. The programme then opens with breathing and positioning, and strengthening is left until later.

How the assessment is carried out

Making a diagnosis is the physician's work. A physiotherapy assessment comes after the physician's assessment and sets out to understand which function the complaint is connected to. If you have recently moved to Turkey and do not yet know how the system works here, this is the usual route. Many women start with the family physician (aile hekimi) at their local family health centre, who looks at the complaint and can direct them on to obstetrics and gynaecology, to urology, or to physical medicine and rehabilitation. That first step is not compulsory, and an appointment at a state hospital outpatient clinic can also be booked directly. In the private route the specialist is normally booked directly as well. Waiting times differ between the two routes, and which one suits you depends on your insurance and your circumstances.

The assessment begins with talking. You will be asked about your pregnancy and birth history, the mode of birth, whether there was an episiotomy or a tear, how the stitches healed, whether you are breastfeeding, your urinary and bowel habits, the moments when leaking happens, how much you drink during the day, and where the pain appears. Alongside that, the weights you lift, your plans for returning to work, your sleep and how the baby is carried through the day are discussed.

Then comes the examination of the trunk. Posture, the position of the rib cage relative to the pelvis, the pattern of breathing, the behaviour of the abdominal wall under load and the tension along the midline of the abdomen are looked at. For this part the upper body is uncovered, and the examination is carried out lying down, then sitting and standing.

The third step is functional testing. What happens during a cough is observed, along with whether the symptom appears during a squat, standing on one leg, a step up, or lifting a weight from the floor. All of these tests can be done without an internal assessment, and they usually give enough information to build the first step of a programme. In practice this part of the appointment is plainer than it sounds: clothes you can move in, a few minutes of walking and standing, and testing in the positions in which you say the symptom appears, which for many women means standing rather than lying on a couch.

Internal assessment, consent and the right to stop

An internal assessment is an examination carried out by hand through the vagina. It gives direct information about the contraction strength of the muscle, its endurance, its capacity to release and the state of the supporting structures. It is not automatic and it is not a standard part of the appointment. Knowing in advance what will happen makes the decision to book an appointment easier, so what follows sets out step by step how the assessment runs.

• What will be done, why it is thought necessary and what is being looked at are explained beforehand.
• Nothing is done without consent. Consent is asked for verbally and it is recorded.
• If you do not want it, it is not done. That choice does not have to be justified, and the rest of the assessment carries on in the same way.
• Assessment is also possible through external observation and functional testing. This route can be chosen at the first appointment, with the internal assessment left to a later date or not done at all.
• You may bring someone with you, and that person can stay in the room throughout.
• The assessment can be stopped at any moment. Saying "stop" is enough, and no explanation is expected.

The door of the room stays closed, a cover is available, and separate time is given for dressing and undressing. The physiotherapist carrying out the assessment is a woman. Sessions are one to one, last 60 minutes and are held by appointment, and consultations can be held in English. A free fifteen-minute introductory call can be arranged beforehand; no examination takes place in that call, and it is used to talk through how the process works.

An internal assessment is postponed during menstruation, when there are signs of an active infection, in the first weeks after the birth, and while stitches are still healing. For that decision to be made, the physician's assessment has to have taken place first.

What the evidence says

The widest answer to the question of whether training this muscle actually helps comes from a Cochrane review published in 2020. The most telling feature of the picture it sets out is that the strength of the evidence depends on when the work begins: the strongest results sit under prevention, in women who are not yet leaking. The reasoning behind starting during pregnancy, and the numbers that go with it, are set out on the exercise in pregnancy page.

The same review found no evidence that training given during pregnancy produces the same benefit in women who are already leaking. That distinction is set out here rather than passed over, because it changes what can honestly be said to a woman who is already leaking. What is missing from the evidence, though, is the answer to one narrow question: the effect, in women already leaking at the time, of training given during the pregnancy itself. It does not follow that nothing can be done for a woman who is leaking. In that situation the plan is built around the type of leaking, the moments when it appears, the capacity of the muscle to contract and to release, and the physician's assessment, and the timing follows from the same assessment. For faecal incontinence the evidence is uncertain, and no firm claim of benefit can be written here. On safety, no difference was found in labour or birth outcomes between women who did pelvic floor muscle training during pregnancy and those who did not.

A similar honesty is needed about the separation along the midline of the abdomen. Structured exercise programmes have been shown to narrow the distance between the muscles measurably, but in the same studies that anatomical narrowing did not turn into an improvement in a woman's day-to-day function. The aim is therefore an increase in load-bearing capacity and a reduction in symptoms rather than the closing of the gap. The detail is on the separation of the abdominal muscles page.

How a programme is built and what moves it forward

The programme is written after the assessment. The strength and duration of the contraction, the capacity to release, the position in which control is lost and the movement in which the symptom appears set the starting point.

Work typically begins in the position where control is easiest to hold and moves over time into sitting, standing, walking and carrying. The length of the contraction, the number of repetitions and the rest interval change along with that progression. Pairing the work with the breath, practising release as a skill in its own right, and reorganising lifting technique belong to the programme. Loads that cannot be put down, such as carrying the baby and the pushchair or lifting the car seat, are taken into account from the start.

How many sessions will be needed cannot be said on the first day. How long it takes depends on the type of symptom and how long it has been present, on the contraction and release capacity of the muscle at the outset, on any accompanying pain, on how far the home programme can be kept up, and on the pattern of daily loading. Whether the programme fits into everyday life matters as much as the time spent in the clinic. The home programme is therefore built around the time a woman can genuinely set aside and the care she is responsible for, and it is rewritten when it turns out not to fit.

Sessions are held at Erzene Mahallesi 113 Sokak No: 1/3. Evka 3 metro station stands in the same neighbourhood and is the eastern end of the M1 line, so a train running that way finishes there and there is no stop to miss. The stop before it on the line is Ege Üniversitesi, which serves the university campus, so the campus and the practice are one stop apart. Bornova station is a separate stop further along the line and serves the district centre.

When to see a physician first

Making a diagnosis, requesting imaging and prescribing medication fall outside a physiotherapist's remit. If any of the findings below is present, a physician should be seen before a physiotherapy appointment.

• Pain, swelling, redness or warmth in one calf. If shortness of breath or chest pain comes with it, emergency care is needed without delay.
• Fever, foul-smelling discharge, or increasing redness or opening where stitches were placed.
• Bleeding after birth that restarts once it had stopped, or that increases unexpectedly.
• Burning on passing urine together with fever and pain in the side of the back.
• Blood in the urine or in the stool.
• Being unable to pass urine at all, or a continuing feeling that the bladder is not emptying.
• Progressive weakness or numbness in the legs, or loss of sensation in the area you sit on. This picture needs to be assessed without delay.
• A sensation of tissue coming down through the vagina, particularly if pain or difficulty passing urine comes with it.
• Severe pain during intercourse, or bleeding afterwards.
• Faecal incontinence that carries on months after the birth.
• Low mood that lasts all day, anxiety, being unable to sleep, or thoughts of harming yourself or the baby. These can appear in the period after birth and are medical conditions that need assessment.

If something worries you and it is not on this list, it is still worth asking a physician. If saying the symptom out loud feels hard, writing it down and handing it over is another way. Staying quiet out of a worry that you may be making too much of it only delays the assessment.

Where to go next in this guide

Which movements are suitable during pregnancy, the recommendation of at least 150 minutes of moderate activity a week, and the warning signs that mean exercise should stop are set out on the exercise in pregnancy page. The gap along the midline of the abdomen, how it is measured and what is regarded as expected are covered on the separation of the abdominal muscles page.

The types of urinary incontinence, which approach comes up in which situation, and where the evidence is strong and where it is weak are on the urinary incontinence after birth page. How the level of activity can be raised from walking to running, and the criteria used when returning to running, are on the returning to exercise after birth page.

The spinal load carried by a woman with scoliosis during pregnancy and after the birth is a separate subject and is dealt with on the scoliosis in adults page. Appointment and travel details are on the contact page.