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What A Doctor Wants You To Know About Pelvic Floor Treatment

“Just because a biological function can be painful doesn’t mean that the pain is acceptable or that you must continue suffering.”

by Dr. Karen Tang
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Pelvic muscle spasm and pelvic dysfunction are extremely common causes of pain and bowel and bladder symptoms, but they are often missed because they don’t show up on imaging or lab work, and they require a specialized pelvic exam to diagnose. I am a gynecologist, and I used to care for patients part-time at a Veterans Administration hospital, and I discovered that almost all the female military veterans who were referred with chronic pain had pelvic muscle issues. Very often, this was caused by a strenuous exercise and work regimen or a physical injury in the past.

Inspired by my work with patients, I’ve written a book, It’s Not Hysteria, about pelvic pain, menopause, abnormal periods, sexual dysfunction, infertility, and others. I wanted to create a revolution for how people understand their bodies and their choices and how the medical community communicates with patients. One of my favorite comedians, Ali Wong, said, “I have suffered enough” when it comes to the physical and emotional challenges of pregnancy and childbirth. Just because a biological function can be painful doesn’t mean that the pain is acceptable or that you must continue suffering. If you are like most people assigned female at birth, you have almost certainly suffered far more than you should have already. The injustice needs to end now, and I’m going to start by arming you with the information that will help you take control of your health.

What Is Pelvic Floor Dysfunction?

Pelvic floor problems are common, and pelvic physical therapy helps prevent pain and distressing vaginal and urinary symptoms. In many people, pain with sex, leaking of urine, difficulty controlling the bladder, or chronic constipation is caused by spasm or dysfunction of the pelvic muscles, and this can be treated with physical therapy. Endometriosis patients commonly have pelvic muscle issues because the endometriosis inflames nearby muscles and nerves. And most people who have given birth have experienced damage to the pelvic floor from the stresses of pregnancy or labor. For this reason, some European countries, such as France, provide pelvic physical therapy for all women postpartum to aid in recovery and prevent symptoms such as urinary incontinence.

Dysfunction of the pelvic floor muscles can cause a wide range of bothersome issues. Just as the muscles of your back, neck, arms, and legs can spasm and become painful, spasming pelvic muscles can cause severe pain. Because they are closely connected to the vagina, rectum, and bladder, spasms in these muscles can also cause functional problems, such as pain with sex, constipation, and incontinence.

Pelvic floor muscle spasm and pelvic dysfunction can occur randomly or can be triggered by injury, infection, or inflammation. Possible triggers are sudden injury of the legs, back, pelvis, or vagina and chronic stresses such as intense exercise or heavy lifting. Runners, dancers, people with very physically strenuous jobs, people who have sexual trauma, and people who have been in car accidents or had other physical injuries are all at risk of developing pelvic floor dysfunction. The pelvic muscles can spasm and become tight and painful, or they can fail to contract normally, leading to difficulty emptying the bladder or having bowel movements.

A surprising cause of pelvic floor dysfunction is hovering over public toilets instead of sitting on the seat. Hovering causes the pelvic floor muscles to tense unnaturally, leading to difficulty relaxing the muscles when trying to urinate or have bowel movements. Pelvic physical therapists recommend that people sit directly on the toilet (with a seat cover if desired) or, even better, use a Squatty Potty, which positions the muscles at the proper angle. Squat toilets, which are common in Asia, Africa, and the Middle East, are toilets located in the floor itself, and users squat over the opening to urinate or defecate. Squat toilets also allow the pelvic muscles to relax in a more natural way while going to the bathroom.

The muscles and nerves of the pelvis and pelvic organs are all interconnected, so multiple issues tend to arise simultaneously. For instance, someone may have symptoms of difficulty urinating, constipation, pain with sex, and chronic pain of the pelvis, lower back, legs, and hips.

How does pelvic floor therapy work?

The main treatment for pelvic floor dysfunction is physical therapy guided by licensed pelvic floor physical therapists. Medications can be used as an adjunct to PT to help relax the muscles or make them less painful.

Many people have heard of Kegel exercises, which involve tightening the pelvic floor muscles for several seconds multiple times throughout the day; this can prevent or limit urinary incontinence. However, pelvic floor physical therapy is far more complex than that. In fact, sometimes doing Kegels can make pelvic floor dysfunction worse because it causes further spasm of the muscles. Pelvic PT is always customized for each individual patient and can include a combination of stretching and releasing tight muscles or trigger points, strengthening weak muscles, retraining the bladder and muscles in normal functioning and relaxation, and coordinating the activity of the muscles.

Physical therapists may guide patients in exercises to control and strengthen the muscles. They may use biofeedback, a technique in which small sensors are placed in the vagina or anus or on the skin around the anus. When the muscles are tightened and relaxed, the pressures achieved are conveyed as a visual display on a monitor or as auditory cues; this helps the patient target the correct muscles and assess improvement in strength and control. Other tools that may be used to help strengthen weak pelvic muscles are electrical stimulation (where a gentle electrical current is used to help activate and contract the muscles) and small plastic or silicone weights, which are held in the vagina to help engage the muscles.

Physical therapists may manually release tight muscles, sometimes using small curved silicone or plastic wands to reach particularly painful or tight spots. If a patient is experiencing vaginismus or uncomfortable vaginal tightening due to menopause or testosterone use, they may also use vaginal dilators. Dilators are narrow, tube-shaped devices that come in different sizes and gently stretch and relax the vaginal walls and pelvic muscles. Starting with the narrowest size, the physical therapist or the patient inserts the dilator in the vagina. Once patients are comfortable with a dilator size, they will move to the next larger size, and hopefully, over time, they will be able to insert tampons or have intercourse without pain. Most physical therapists will teach patients how to use dilators so they can continue their exercises at home.

Many people feel anxious or confused about what they might experience during pelvic PT. Pelvic physical therapists understand that patients may be nervous, and they know that many people who have pelvic floor issues have experienced sexual trauma or feel uncomfortable with vaginal exams. They will work within each patient’s comfort level and pace, allowing the patient to feel safe and centered in the experience.

What medications treat pelvic floor injuries?

Sometimes pelvic PT can be augmented with certain medications; they don’t take the place of PT but they can help make PT more comfortable or effective. There is very little research about medications for the treatment of pelvic floor dysfunction — their use is often based on findings extrapolated from other types of chronic pain or muscle spasms. In fact, all the following medications are technically off-label for use in treating pelvic pain, meaning that they are not officially approved by the FDA for the treatment of these symptoms. Because some people do find them helpful for pelvic floor issues, they may be worth discussing with your doctor.

Oral Medications

Gabapentin (Neurontin) is an antiseizure medication that is used for the treatment of nerve-related pain. Certain types of antidepressants, such as amitriptyline, can actually improve pain as well as bladder and bowel symptoms, so they are sometimes used for IC or irritable bowel syndrome. Muscle relaxants such as cyclobenzaprine can also temporarily relieve pelvic muscle spasm. All these medications can cause side effects such as sedation and dizziness, and people sometimes stop using them because they find the side effects bothersome.

Vaginal Suppositories and Creams

It is possible for the above medications to be made into vaginal suppositories, which have fewer side effects than pills. Vaginal suppositories come in different shapes, are small, and can fit comfortably inside the vagina. Another medication that can be used in this way is diazepam (Valium), which is commonly used to treat anxiety. The data is conflicting on whether vaginal diazepam has a significant effect on pelvic floor spasm. Some studies show it improves pain scores and patients can feel a difference in their pelvic floor symptoms.

Vaginal suppositories are prescribed for people to insert at home if they experience pain or to use around the days that they will undergo PT. A limitation in their use is that they must be created by compounding pharmacies, as they are not available from traditional commercial pharmacies.


For patients with painful trigger points, another treatment option is trigger point injections. A combination of a local anesthetic to numb pain and a steroid to decrease inflammation are injected into the trigger point. These injections can also treat nerve conditions such as sciatica and piriformis syndrome.

Pelvic floor botulinum toxin (Botox) injections may help with severe muscle spasm, and when injected into the bladder wall, they can improve symptoms of urinary frequency or urgency. This is an expensive treatment that may not be covered by insurance.

Trigger point and botulinum toxin injections are usually administered in the doctor’s office by urogynecologists. Though the injections are given with a local anesthetic to numb the area, it’s possible to feel some initial pain when they are administered, and some patients prefer to have them performed when they’re under sedation. Several treatments over weeks or months may be necessary to provide sufficient pain and symptom relief.

Dr. Karen Tang is a board-certified gynecologist and minimally invasive gynecologic surgeon. As @KarenTangMD on TikTok, Instagram, and YouTube, she reaches millions of viewers across the world each month with her educational videos about period health, pelvic pain, gender affirming healthcare, and reproductive rights. Her goal is to break down the stigma around reproductive health, and empower people to take control of their health. She wrote her new book, It’s Not Hysteria, to help people understand their bodies and their choices and to change how the medical community communicates with patients.

Excerpted from It’s Not Hysteria: Everything You Need to Know About Your Reproductive Health (but Were Never Told), Copyright © 2024 by Karen Tang. Excerpted by permission of Flatiron Books, a division of MacMillan Publishers. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.