The Pelvic Floor Connection Sex Therapists Wish More People Knew

The public conversation about the pelvic floor is almost entirely about weakness: postnatal leaking, prolapse, and an instruction to do Kegels while waiting for the kettle.

Pelvic health physiotherapists spend a substantial part of their week treating the opposite problem, in women who have been told for years to squeeze harder.

Muscles, not a mystery

The pelvic floor is a sling of skeletal muscle running from pubic bone to tailbone. Like any muscle group it can be weak, it can be tight, and it can be both at once — weak because it is chronically shortened and never fully relaxes.

Its role in orgasm is direct: rhythmic contraction of these muscles is the physical event. Blood flow and sensation depend on them too.

The signs of too much tone

Pain with penetration or with tampons. Urinary urgency and frequency without infection. A feeling of incomplete emptying. Constipation. Pain that lingers after sex. Reduced sensation and difficulty reaching orgasm.

“These patients have almost always been told to do more Kegels,” says Lorna Fitzgerald, MCSP. “They are already gripping. Asking them to grip harder is the exact opposite of the treatment.”

What causes it

Chronic stress, which produces a genuine and measurable clenching response. High-impact training and heavy lifting with a breath-holding pattern. A history of painful sex or of gynaecological trauma, where guarding becomes automatic. Endometriosis and recurrent infections, where the muscle protects a painful area and then keeps doing it after the cause resolves.

What helps

Diaphragmatic breathing, with attention on the release phase — the pelvic floor descends on the in-breath. Hip and adductor mobility work. Deliberate down-training, which is the physiotherapy term for learning to fully let go.

Internal manual therapy from a pelvic health physiotherapist is the gold standard and is available on referral in most health systems. Dilator therapy is evidence-based for vaginismus and works best supervised.

The line worth repeating

Painful sex is common and it is not normal, in the sense that it is not something to accept.

“Vaginismus, vulvodynia, endometriosis and genitourinary syndrome of menopause are all treatable,” says Dr Boateng. “The average delay before someone raises it with me is measured in years, and those years are avoidable.”